49 years old gentleman, ex-smoker, had history of acute anteroseptal myocardial infarction (November 2022), Killip 1, TIMI score 1, successfully thrombolysis with IV infusion streptokinase. During follow up, he is Canadian Cardiovascular Society (CCS) Angina Grade 1 with complained of mild symptoms angina with strenuous and prolonged exertion. He is hemodynamically stable with blood pressure 120/78 mmHg, manual pulse showed regular rhythm with 88 bpm. Physical examination showed unremarkable. 

ECG showed sinus rhythm with Q wave anteroseptal region, T inversion V1 to V3. Echocardiogram showed normal LV function with EF 54%, anterior wall hypokinesia, normal chamber, all cardiac valve thin well coaptation, no regurgitation and stenosis, no clot or thrombus, no pericardial effusion.Haemoglobin- 14.6 g/dL, Renal profile - Creatinine 98 umol/L, Urea 5.6mmol/L, Total cholesterol 3.0 mmol/L, LDL 1.3 mmol/L, HDL 1.2mmol/L, Triglycerides 1.1 mmol/L, Random blood sugar -7.8 mmol/L

He had diagnostic coronary angiography on 21/5/2023, which showed a single vessel disease (SVD) with ostial left anterior descending artery (LAD) 95 % stenosis, with post stenosis aneurysmal and mild disease in distal LAD (20%). Mid left circumflex artery showed mild coronary artery disease with 20 % stenosis which is also aneurysmal. He has a high branch of first obtuse marginal artery(OM1) where proximal of OM1 showed 30% stenosis. He had a normal Right coronary artery vessel. 

Percutaneous Coronary intervention was done via 6 Fr right radial approach. Total of IA 8000 units heparin and 300 mg oral clopidogrel given. Left coronary system was engaged with 6 Fr EBU 3.0 mm, successfully wired down to distal LAD with balance middleweight guide wire (BMWII J Tip). We tried to Pre-dilate ostial LAD with non-compliant (NC) balloon3.5 mm x 15 mm but unfortunately was unable to pass through tight lesion in ostial left anterior descending artery (LAD). So, we used a smaller size semi-compliant (SC) balloon 2.5 mm x 15 mm. We then predilate further with NC balloon 3.5 mm x 15 mm. It was able to cross the tight lesion of ostial left anterior descending artery (LAD), with slow and prolonged inflation and up to24 ATM, equivalent to 3.65 mm size. Lesion was well predilated to 1:1 ratio with no flow-limiting dissection, we proceeded to deploy Paclitaxel Drug coated balloon, PREVAIL 4.0 mm x 20 mm, up to 8 ATM, for 1 minute. Final result showed acceptable result with residual stenosis 30% and was end with total contrast used 100 cc, screening time 25 mins. He was discharged well next day with dual antiplatelet for 3 months. He remained asymptomatic and re-look coronary angiography after 3 months (August 2023), showed positive remodeling of ostial left anterior descending coronary artery (LAD) with no new lesion in other coronaries vessel. Patient remained completely asymptomatic. 

Reason for choosing a Drug Coated Balloon is due to a size discrepancy in post stenotic aneurysm which poses risk of inadequate stent opposition and expansion if we were to implant a stent and higher risk of in-stent restenosis. Besides, we do not have self- expandable stent to allow optimal adaptation of the stent struts to the vessel wall in order to reduce the occurrence of stent malposition. Although evidence of DCB in de novo large and ostial lesion is limited but examples of studies shown promising and good results as compare to DES. We had demonstrated good clinical and angiographic outcome in de novo ostial post-stenotic aneurysmal LAD stenosis.